GOOD RESULTS IN PSYCHIATRIC HEALTH CARE AND FACTORS AFFECTING THEM IN FINLAND AND IN GREECE

GOOD RESULTS IN PSYCHIATRIC HEALTH CARE AND FACTORS AFFECTING THEM IN FINLAND AND IN GREECE HELMI TIRI Faculty of Medicine, Department of Nursing Science and Health Administration, University of Oulu Joint Authority of Kainuu Region OULU 2005 Abstract in Finnish

HELMI TIRI GOOD RESULTS IN PSYCHIATRIC HEALTH CARE AND FACTORS AFFECTING THEM IN FINLAND AND IN GREECE Academic Dissertation to be presented with the assent of the Faculty of Medicine, University of Oulu, for public discussion in the Martti Hela Hall of the Research and Development Centre of Kajaani (Seminaarinkatu 2), on June 17th, 2005, at 12 noon OULUN YLIOPISTO, OULU 2005

Copyright 2005 University of Oulu, 2005 Supervised by Professor Juhani Nikkilä Reviewed by Professor Jukka Aaltonen Professor Ismo Lumijärvi ISBN 951-42-7752-X (nid.) ISBN 951-42-7753-8 (PDF) http://herkules.oulu.fi/isbn9514277538/ ISSN 0355-3221 http://herkules.oulu.fi/issn03553221/ OULU UNIVERSITY PRESS OULU 2005

Tiri, Helmi, Good results in psychiatric health care and factors affecting them in Finland and in Greece Faculty of Medicine, University of Oulu, P.O.Box 5000, FIN-90014 University of Oulu, Finland, Department of Nursing Science and Health Administration, University of Oulu, P.O.Box 5300, FIN-90014 University of Oulu, Finland; Joint Authority of Kainuu Region, Sotkamontie 13, FIN-87140 Kajaani, Finland 2005 Oulu, Finland Abstract The aim of this study was to compare the development of the psychiatric health care services, the views about what things can be regarded as good results in psychiatric health care and the factors affecting on them in Finland and in Greece. The study can be used as a point of reference when developing and comparing mental health indicators in and between the European countries. The psychiatric health care services in both the countries appeared to have gone through similar phases of development: isolation, psychopharmacal treatment, work and other activities, psychotherapies and finally, patient-oriented combination of all the methods. The number of psychiatric in-patient beds has decreased in mental hospitals and increased in general hospitals, and the number of rehabilitation and service homes has also increased. The data sets were collected by interviews and from written documents and statistical data sets concerning Finland and Greece (OECD health care data set 2000, European Commission 1997, 1999a, 1999b, 2000, 2001, World Health Organization 1996a, 1996b, 2001a, 2001b). In Finland 44 workers and decision-makers were interviewed within the area of one hospital district, and in Greece, 35 workers were interviewed in two psychiatric hospitals. The qualitative data sets were analyzed with methods of content analysis. The international and national quantitative data were analyzed for similarities and differences. The frame for the comparison was outlined based on the literature and the results of the interviews. In both countries, good results in psychiatric health care included well-being, functional abilities, service capacity and economy. Well-being in both the countries meant alleviation of the symptoms of the illness and satisfaction of the basic physical, psychic and social needs. In Finland patients' positive feelings were emphasized, while in Greece, the value of of equal rights for sick and healthy people was underlined. Functional abilities included the ability to take care of one's everyday life. In Greece the long-term mental patients needed to relearn the skills of daily living, while the Finnish system emphasized patients' ability to use the skills they had but did not use because of their illness. Adequate service capacity in Greece meant the accessibility of the services close to each person's place of residence, while in Finland possibilities to get information and guidance about matters concerning oneself and one's relatives were considered especially important. Economy meant the relationship between the costs and the results. In Greece patients needed sufficient pensions to be able to live outside the hospital. In Finland the challenge was to produce sufficiently high-quality services with the available resources. The factors affecting good results were related to the patient/client and his/her relatives, the health care staff, the methods of treatment, the organization of the system of care and the society in question. The importance of the patient's family, the professional skills of the staff, and the availability of both outpatient and inpatient treatment and medication were emphasized. Keywords: comparative research, economy, functional abilities, good results, psychiatric health care, service ability, well-being

Tiri, Helmi, Psykiatrisen terveydenhoidon tuloksellisuus ja siihen vaikuttavat tekijät Suomessa ja Kreikassa Lääketieteellinen tiedekunta, Oulun yliopisto, PL 5000, 90014 Oulun yliopisto, Hoitotieteen ja terveyshallinnon laitos, Oulun yliopisto, PL 5300, 90014 Oulun yliopisto; Kainuun maakunta -kuntayhtymä, Sotkamontie 13, 87140 Kajaani 2005 Oulu, Finland Tiivistelmä Tutkimuksessa vertaillaan psykiatrisen terveydenhoidon kehitystä sekä käsityksiä hoidon tuloksellisuudesta ja siihen vaikuttavista tekijöistä Suomessa ja Kreikassa. Tutkimusta voidaan käyttää yhtenä esimerkkinä kehitettäessä psykiatrisen hoidon indikaattoreita ja maiden välisiä vertailuja Euroopassa. Tulosten perusteella psykiatrisessa terveydenhoidossa on havaittavissa molemmissa maissa tietyt kehitysvaiheet: eristäminen, lääkitys, työ ja toiminta, psykoterapiat, ja viimeisimpänä edellä mainittujen potilaslähtöinen yhdistäminen. Sairaalapaikkojen määrä psykiatrisissa sairaaloissa on vähentynyt ja yleissairaaloissa lisääntynyt molemmissa maissa ja kuntoutus- ja hoitokotien määrä on lisääntynyt. Aineisto koottiin haastatteluilla, kirjoitetuista asiakirjoista sekä tilastotiedoista psykiatrisesta terveydenhoidosta Suomessa ja Kreikassa (OECD health care data set 2000, European Commission 1997, 1999a, 1999b, 2000, 2001, World Health Organization 1996a, 1996b, 2001a, 2001b). Suomessa haastateltiin 44 työntekijää ja päättäjää yhden sairaanhoitopiirin alueella, Kreikassa 35 kahdessa sairaalassa. Laadullinen aineisto analysoitiin sisällönanalyysimenetelmällä. Kvantitatiivisesta, kansallisista ja kansainvälisistä lähteistä kootusta aineistosta etsittiin samankaltaisuuksia ja eroavuuksia. Vertailun viitekehys muodostettiin kirjallisuuden ja haastattelujen tulosten perusteella. Psykiatrisen terveydenhoidon tuloksellisuus on molempien maiden tiedonantajien mukaan hyvää oloa, toimintakykyä, palvelukykyä ja taloudellisuutta. Hyvä olo tarkoittaa sairauden oireiden lieventymistä ja psyykkisten, fyysisten ja sosiaalisten perustarpeiden tyydyttymistä. Suomessa korostettiin potilaan myönteisiä tunteita, kreikassa ihmisarvoa samanlaisin oikeuksin kuin muillakin ihmisillä. Toimintakyky sisältää kyvyn huolehtia jokapäiväisen elämän vaatimista tehtävistä. Kreikassa pitkään sairastaneilla oli tarve opetella uudelleen alusta jokapäiväisen elämisen taitoja, Suomessa korostettiin sairauden vuoksi käyttämättömänä olevan osaamisen elvyttämistä. Palvelukyky tarkoitti Kreikassa palvelujen saatavuutta läheltä asuinpaikkaa, Suomessa tiedon ja ohjauksen saamista itseä ja läheisiä koskevissa asioissa. Taloudellisuus tarkoittaa kustannusten ja tulosten välistä suhdetta. Kreikassa potilaiden tulee saada parempia eläkkeitä kyetäkseen asumaan sairaalan ulkopuolella, Suomessa haasteeksi koettiin hyvän hoidon mahdollistaminen olevilla voimavaroilla. Tuloksellisuuteen vaikuttavat tekijät liittyivät potilaaseen/asiakkaaseen ja hänen läheisiinsä, hoitavaan henkilökuntaan ja hoitomenetelmiin, hoidon organisointiin sekä yhteiskuntaan, jossa eletään. Molemmissa maissa korostettiin potilaan läheisten merkitystä, henkilökunnan ammattitaitoa, hoitopaikkoina sekä avo- että sairaanhoitoa ja lääkehoitoa. Asiasanat: hyvä olo, palvelukyky, psykiatrinen terveydenhoito, taloudellisuus, toimintakyky, tuloksellisuus, vertaileva tutkimus

Think about what you really want because you will have no possibility to start from the beginning again Mieti mitä todella tahdot, koska takaisinpaluuta ei ole Heikille Minnalle, Sannalle, Outille ja Päiville

Acknowledgements I first visited Greece in 1985 my first time to Greece with my family and a group of friends. When I returned home I said: I want to learn the language of that country. At that moment I had no idea about how long and difficult a journey I was starting. This study was carried out at the Department of Nursing and Health Administration, University of Oulu. I owe my thanks to professor Maija Hentinen, who supported me to study abroad and I wish to thank my supervisor, professor Juhani Nikkilä for his patient, demanding and encouraging guidance. The first great persons to help me in Greece were the professors Afrodite Raya and Vassiliki Lanara from the University of Athens. I want to thank all the lovely people I met and got help from in Dromokaiteio Hospital, especially director of nursing services Anette Kristali. She helped me in every question I had and she made it possible for me to enter and stay on the wards of the hospital. In the Evangelismos Hospital assistant director of nursing services Maria Priami arranged for me to stay on the hospital s psychiatric ward and to conduct interviews there. In appendix 7 I present the part of the study carried out in Greece as a gesture of appreciation toward those Greek readers who promoted the study but master their own language better than English language. I wish to thank all the interviewees in Finland and in Greece and all the lovely helpful people I met in Athens. I thank the reviewers Jukka Aaltonen and Ismo Lumijärvi for their friendly and accurate comments and allowing my work able to be published. Sirkka-Liisa Leinonen I want to thank for specialized language consultation. Joint Authority for Specialized Health Care and Social Welfare in Kainuu ( = Joint authority of Kainuu Region) has supported my work and without this support, the study would never have been accomplished. I wish to thank chief executives and medical directors for these arrangements. My special thanks go to planning director Tarja Kiira for listening to my hardships and joys and for pushing me forward. Chief physician Mauno Saari is thanked for understanding and reassuring me when I was totally frustrated. My sincere thanks go to charge nurse Arja Heikkinen, who worked as my substitute during my leaves and thus made possible for me to concentrate on writing.

Warm thanks are due to my daughters Minna, Sanna, Outi and Päivi who have appreciated my way of living by studying all my life long. This study is dedicated to them and to my husband Heikki who has traveled with me in Greece and forced me to sit by the computer at the times when I would have been ready to leave everything unfinished. Now that I am finishing this study I still do not master the Greek language but I am on my way and there is no possibility or need to go back to the beginning.

Abbreviations and synonyms The following abbreviations and synonyms are used in this study: Finland (Fin) In the qualitative analysis, this means information obtained from the Kainuu area in Finland KASS Joint Municipal Authority for Health Care and Social Welfare in Kainuu, Finland, from 1.1.2005 Joint Authority of Kainuu Region Greece (Gr.) In the qualitative analysis, this means information mostly obtained in the Dromokaiteio and Evangelismos hospitals (in the Attica area/ Athens and its surroundings) IKA Social Security Organization (IKA) in Greece, established in 1934 OGA Organization of Agricultural Insurance in Greece, established in 1961 TEVE Fund for Merchants, Manufacturers and Small Businessmen in Greece, established in 1934 TEI Technological Educational Institution in Greece GDP Gross Domestic Product U.S.S.R Union of Soviet Socialist Republics EU European Union NATO North Atlantic Treaty Organization OECD Organization of Economic Cooperation and Development STAKES National research and development centre for welfare and health, Finland WHO World Health Organisation

Contents Abstract Tiivistelmä Acknowledgements Abbreviations and synonyms Contents 1 Introduction...15 2 Purpose of the study and research questions...18 3 Good results of service activities...20 3.1 Components of good results in the service activities...20 3.2 Good results in health care...23 3.3 Good results in the psychiatric health...24 3.3.1 Task of the psychiatric health care...24 3.3.2 Effectiveness in psychiatric health care...25 3.3.3 Service ability in psychiatric health care...29 3.3.4 Economy in psychiatric health care...29 4 Factors affecting good results in psychiatric health care...31 4.1 Mentally ill person and his/her family...31 4.2 Health care staff...36 4.3 Methods of treatment...37 4.4 Organization of the services...41 4.5 Society...44 5 Summary of the background...47 6 Comparative research...51 6.1 Starting point for comparative research...51 6.2 Comparative studies...52 7 Ethical considerations...60 8 Material and analysis...61

9 Results...67 9.1 Development of the psychiatric health care services in Finland and in Greece...67 9.1.1 Resources for the psychiatric health care...72 9.1.2 Expenditure on health...75 9.1.3 Health status...76 9.1.4 Comparison...77 9.2 Good results in the psychiatric health care...78 9.2.1 Finnish views...78 9.2.1.1 Well-being...79 9.2.1.2 Functional abilities...79 9.2.1.3 Service ability...80 9.2.1.4 Economy...80 9.2.2 Greek views...81 9.2.2.1 Well-being...81 9.2.2.2 Functional abilities...82 9.2.2.3 Service ability...82 9.2.2.4 Economy...83 9.2.3 Comparison...83 9.3 Factors affecting good results...85 9.3.1 Finnish views...85 9.3.1.1 Factors related to the patient and his/her relatives...85 9.3.1.2 Factors concerning the staff...87 9.3.1.3 Factors concerning the methods of treatment...89 9.3.1.4 Factors concerning the organization of treatment...90 9.3.1.5 Factors concerning society...91 9.3.2 Greek views...92 9.3.2.1 Factors related to the patient and his/her relatives...92 9.3.2.2 Factors concerning the staff...95 9.3.2.3 Factors concerning the methods of treatment...96 9.3.2.4 Factors concerning the organization of treatment...97 9.3.2.5 Factors concerning society...98 9.3.3 Comparison...99 10 Conclusions: modeling and discussion...105 10.1 Discussion about the findings...105 10.1.1 Development of psychiatric health care services...105 10.1.2 Good results in psychiatric health care...107 10.1.3 Factors promoting good results in psychiatric health care... 110 10.2 Validity and restrictions of the study... 111 10.2.1 Problems of comparability... 113 10.3 Conclusions... 114 10.4 Suggestions for further studies... 115 References Appendices

1 Introduction The purpose of this study was to compare the development of the psychiatric health care services available for adults in Finland and Greece and Finnish and Greek people s views of psychiatric health care: what things can be considered good results in psychiatric health care, and what factors affect them. The statistical information used to supplement the qualitative data broadens the picture of the situation in the selected contexts. The aim is to enhance our knowledge and understanding of psychiatric health care services available for adults in Finland and in Greece. The results can be used in the international co-operation and to assess, compare and develop services and to make further decisions about the indicators to be used in national and international comparisons of psychiatric health care. Finland lies at the very northern periphery of Europe, while Greece, officially called the Hellenic Republic, is located in southeastern Europe. The surface area of Finland is 2.5-fold compared to that of Greece, but Greece has twice as many inhabitants as Finland (table 1). The most densely populated areas of Finland are in the southern and western parts of the country. Almost one fifth of the Finnish population lives in the greater Helsinki area. The percentage of urban population in 1999 was about 60%. More than three million out of the ten million Greek people live in Athens, while the rest are mostly dispersed in rural towns and villages. The terrain of Greece is mountainous, and there are about 400 inhabited islands with difficult access. (McCarthy & Rees 1992, WHO 1996a, WHO 1996b.) Greece has been an independent state nearly a hundred years longer than Finland. It has belonged to the European Union fourteen years longer than Finland (WHO 1996a, WHO 1996b). In 1999, the proportion of people getting their incomes from agriculture was almost threefold in Greece compared to Finland. In 1999, Greece had a sevenfold capacity for tourist accommodation (hotels, etc.) (7946) compared to Finland (1004). (European Commission 2001.) Families usually have one or two children in both countries (OECD Health Data 2000). Education is free of charge and compulsory for nine years in both countries. In 1999, the percentage of population aged 25-29 having completed at least senior secondary education was 74.5% in Finland and 53.9% in Greece. The majority of Greeks belong to the Greek Orthodox Church, and the majority of Finns to the Evangelic-Lutheran Church. (WHO 1996a, WHO 1996b, European Commission 1999b, 2001.)

16 Table 1. Demographic and socio-economic details of Finland and Greece (WHO 1996a, WHO 1996b, European Commission 1999b, 2001). Geographical location - latitude Finland Between 60 and 70 degrees Greece Between 35 and 42 degrees Surface area 338145 km 2 131957 km 2 Inhabitants about 5.1 million in 1997 about 10.5 million in 1997 Year of independence 1917 1830 Wars 1918 Civil war 1939-1940 Winter war 1940-1941 Continuation war 1944-1945 Lapland war 1913 Crete and the Aegean islands were incorporated into Greece 1941-1944 Germans occupied the country 1946 Civil war 1947 The Dodecanese islands were restored back to Greece (1967-1974 Military dictatorship) Government Republic During 1832-1972 a kingdom Since 1973 a republic Language Finnish and Swedish Greek Member of EU from 1995 from 1981 Member of NATO no from 1949 Climate warm and light summers, dark and cool winters snow all over the country in Helsinki in July +12-22 0 C, in February 9- -4 0 C Mediterranean climate In Athens in July 23-33 0 C, in February 6-13 0 C In winter snow on the mountains Nature about 65% forest, 10% water, 8% cultivated land 70% of land area mountainous, 20% forest, 30% cultivated land Taxation Municipal taxes, state taxes, church taxes Municipal taxes, state taxes Religion Evangelic-Lutheran Church (86%) Greek Orthodox Church (98%) Education Compulsory school age from seven to fifteen Compulsory school age from six to fifteen Literacy rate 100% 94% Source of income (in 1997) agriculture 6.4% industry 27.7% services 65.9% agriculture 17.0% industry 22.9% services 60.1% Gross domestic product (GDP) in items of purchasing power standards per head in 1994 was 15099 in Finland and 10561 in Greece, the medium in Europe being 16641 (European Commission 1997). In 1999, it was 20886 in Finland and 14277 in Greece, that in EU being 20613. (European Commission 2000.) Final household consumption was twofold in Finland compared to Greece (European Commission 2000, table 2).

17 Table 2. Final household consumption per head (in constant European Currency Units) in Finland and in Greece (European Commission 2000). Year Finland Greece Europe 1982 6955 2877 6099 1985 9454 4176 7741 1997 10968 5217 9659

2 Purpose of the study and research questions Using the means of comparison, the purpose of this study was to increase knowledge and understanding concerning similarities and differences in the psychiatric health care services for adults in Finland and Greece. The findings of the study can be used to facilitate international cooperation, to develop and compare services, and to choose indicators to be used in international comparisons of psychiatric health care. People s views deepen and confirm the information about the contents of the indicators. The statistical information used--according to the selected framework-- along with qualitative data, broadens the picture of situations in selected contexts. Through comparisons, the researcher systematically explains and/or interprets the differences and/or similarities between the studied subjects. The areas of comparison in this research were: 1. The development of psychiatric health care services in Finland and Greece 2. Views about good results in psychiatric health care in Finland and Greece 3. Views about factors affecting good results in Finland and Greece This comparative study got its very start from the study Charge nurse as a manager (Tiri 1994), in which management by results was the theoretical background.. This increased my personal interest in people s views on good results in psychiatric health care and factors affecting these positive results. I also wished to compare situations and people s perspectives regarding psychiatric health care in different countries--in this case, those in Finland and Greece. People s views guide their actions and should therefore be recognized and considered when planning and implementing services (McKenna 1999). The framework for the comparison arose from interviews, literature, and data sets collected from both countries. Since I had worked in psychiatric health care, I had some existing understanding of the topic. Before collecting the Finnish data, I had read studies and literature concerning the subject. After the analysis of the data, I systematically searched for earlier studies and reflected the results of the analyses with them. Next, I compared the development of psychiatric health care, views about good results around this issue, and factors which have affected the views and development of psychiatric health care in these two countries. In chapter three, after defining good results in service activities in general, and good good results in health care, good results in

19 psychiatric health care will be discussed. Factors affecting these good results will be considered in chapter four. The methodology of comparative study is presented in chapter six, and ethical considerations in chapter seven. Chapter eight covers data collection and analysis. The development of psychiatric health care services, views about good results in this field, and affecting factors are described and compared between Finland and Greece in chapter nine. The tenth chapter will discuss the findings of the study, as well as its validity and restrictions. Finally, conclusions of this study and topics for further studies are presented.

3 Good results of service activities 3.1 Components of good results in the service activities Good results of service activities refer to the criteria, which are used to evaluate how good a function is. Good results imply success. The term good result can be defined in a limited sense as the degree to which a goal is attained, which makes good result synonymous with the term effectiveness. It can also be used in a broader sense as a concept, which includes productivity and/or economy, effectiveness and service ability (which can be further divided into internal and external service ability). The use of result indicators became common in the public sector as a consequence of management by objectives and management by results in the seventies and eighties. Result indicators originated in Taylor s work of emphasizing the exact measuring of results as a part of scientific management. (Taipale 1988, Meklin 1989, Hiironniemi 1992, Lumijärvi 1997, Lumijärvi 1999). Hiironniemi (1992) has defined good results of activities as consisting of the following components: external effectiveness/cost-effectiveness, external service ability, and internal service ability and productivity/economy (fig.1). Citizens needs form the basis for production of the services. GOOD RESULTS EXTERNAL INTERNAL EFFECTIVENESS COST- EFFECTIVENESS EXTERNAL SERVICE ABILITY INTERNAL SERVICE ABILITY PRODUCTIVITY ECONOMY Fig. 1. Parts of good results of activities (Hiironniemi 1992).

21 Kaplan & Norton (1996) have defined good results of a business organization as an aggregate of financial and customer perspective, learning and growth of the staff, and fluency of processes. The underlying basis of good results is the vision and strategy of the organization. In order to measure the good results of the activities there is the need for assessment and decision making about the level of the indicators on which the achievements are desired. (Kuusela 2001.) The Commission for Local Authority Employers in Finland (2003) has defined the components of good results (fig.2) according to balanced scorecard (Kaplan & Norton 1996). The first one is effectiveness, sufficiency and allocation of the services. The second is quality of the services and client satisfaction, accessibility of the services and co-operation between the service units. The third component includes productivity, economy and fluency of the service processes and the fourth one efficiency of the staff, like know-how, innovativity, job satisfaction, motivation and working ability. The components are in continuous interaction with each other. Financial perspective - productivity, - economy and fluency of service processes Customer perspective - effectiveness, - sufficiency and allocation of services VISION AND STRATEGY Internal processes - quality of the services and - client satisfaction, - accessibility of services and cooperation. Learning and growth perspective - efficiency of the staff, know-how, innovation, job satisfaction, motivation and working ability Fig. 2. Components of good results according to the Balanced Scorecard (Kaplan & Norton 1996). Productivity as a component of good results means the relation between the output--in other words, the amount of performances--and the input needed to produce it (Ahonen 1985, Taipale 1988, Kunnallinen työmarkkinalaitos 1989, 2003, Hiironniemi 1992, Uusi- Rauva 1993). Productivity can be divided into productivity of labour, capital and material input. Productivity of labor refers to the relation between the work input and output. The

22 work input consists of working time, working hours, and working years. It also means occupied posts, the number of staff, and the costs of labour. (Liukkonen & Suurnäkki 1994, Sinkkonen & Kinnunen 1994, Vartiainen 1994.) While developing the productivity of activities, attention is directed upon developing technology, production methods, enterprise organizations, business administration, and education of the staff. An increase in productivity improves competitive ability and alleviates the pressure to raise prices. (Kuparinen 1993.) Economy means the relation between costs and output; in other words, how much financial resources have been used to achieve a certain amount of outputs. Economy is manifest in the attempt to provide as many high quality outputs as possible at the lowest possible cost. (Taipale 1988, Meklin 1989, Hölttä 1991, Hiironniemi 1992, Jyrkkiö & Riistama 1994, Vartiainen 1994, Kunnallinen työmarkkinalaitos 1998, 2003, Lumijärvi 1998.) Costs can be divided into variable costs and fixed costs. Fixed costs of a working unit come from rents, heating, and cleaning, for instance. The variable costs include, among other things, salaries, overtime compensations, supplies and repair and service of the machines. (Jyrkkiö & Riistama 1994.) Kaplan & Norton (1996) describe from the financial perspective there to be three kinds of firms, depending on whether the business is in a growth, sustain, or harvest stage. Growth businesses have products or services with significant growth potential. Financial objectives are based on sales volumes, existing and new customer relationships, and process development. A business unit in a sustain stage must earn excellent returns on invested capital. These firms are expected to maintain their existing market share and perhaps to grow in some area from year to year. Harvest businesses want to get profit from their investments. They have reached the mature phase of their life cycle. The same phenomenon can be seen in health care. Growth businesses in the health care industry, during the last ten or twenty years, have consisted of private services and nursing homes, for instance. These businesses receive their income from the patients or residents and the municipalities or the state, depending on the country and the region. In Finland and Greece, the number of these private services and homes has increased since the 1970 s. A critical challenge for the homes in the sustain and harvest stages is keeping the clientele settled and making a profit from the work, while maintaing a high quality of service. (Venla-workgroup 1995, Tsiandis 1995). Effectiveness of the activities means the ability to satisfy the client s needs and to achieve the goals which have been set. The goals can be set by society or on the basis of the needs of the citizens. Effectiveness can be measured by the change in client situations, which has been achieved by the activities. (Kunnallinen työmarkkinalaitos 1989, Alander et al. 1990, Hölttä 1991, Hiironniemi 1992, Lumijärvi 1999.) Effectiveness can include evaluation of sufficiency and allocation of services. It can be measured by asking the clients what is of benefit of the activities to them, taking into account the number of clients and the number of those queuing for services and getting services. Effectiveness is also measured by assessing the allocation of services, the extent of services for each group, and the resources used for the services for each group. (Kunnallinen työmarkkinalaitos 2003). Cost-effectiveness is the relation between the costs and the effectiveness and quality of the services. The smaller the ratio, the more effective the operation is. (Hiironniemi 1992, Liukkonen & Suurnäkki 1994, Kunnallinen työmarkkinalaitos 2003).